Heart catheter procedures guided by magnetic resonance imaging (MRI) are as safe as X–ray–guided procedures and take no more time, according to a pilot study conducted at the National Institutes of Health. The results of the study indicate that real–time MRI–guided catheterization could be a radiation–free alternative to certain X–ray–guided procedures.

A report of the study, which was conducted by researchers within the intramural program of the NIH’s National Heart, Lung, and Blood Institute (NHLBI), is available online in the European Heart Journal.

Clinical heart catheter procedures are possible without using radiation, which could be especially valuable in areas such as pediatrics.

The research team performed transfemoral catheterization (guiding a catheter from the large vein in the leg to the heart) in 16 patients to examine the right side of the heart, including the attached veins and the pulmonary arteries. The study volunteers all needed catheterization for heart and valve disease. The researchers performed the procedure in the 16 patients using X–ray guidance, and then repeated it twice using real–time MRI guidance of a balloon-tipped catheter filled with air or with a contrast agent.

The MRI and X–ray catheterizations were successful in 15 of the 16 participants. One patient had required the use of a wire to help guide the catheter under X–ray, and currently no guidewires are available that work under an MRI.

The average procedure time for the two approaches was comparable — about 20 minutes. The team expected the MRI–guided procedure to take much longer because an MRI–compatible catheter can be harder to see in an MRI–generated image than a conventional steel catheter can be in an X–ray–generated image.

Developing safe and conspicuous catheter devices for MRI is the chief obstacle to overcome before this approach can be widely applied at hospitals. But with improved tools and further improvement of the procedure, real–time MRI catheterization may become a realistic option for many people.

A comprehensive metabolic panel, complete blood count, and thyroid function tests can identify metabolic conditions that may be causative as well as secondary anemia that will indicate further evaluation.

Release of the NATIONAL APPEAL to End Stigma and Discrimination against People Affected by Leprosy

National News

Awareness programme on sepsis tomorrow

HYDERABAD: Calling sepsis a medical emergency akin to heart attack or stroke, city–based critical care experts said here on Tuesday that the lesser known sepsis is killing more people than HIV/Aids, prostate and breast cancer combined globally. Experts were speaking during the announcement of the first World Sepsis Day, to be observed in the city on September 13. The day will mark the first step forward to draw attention of the public as well as healthcare professionals towards tackling the growing incidence of sepsis and subsequent deaths. Sepsis, doctors said, remains the primary cause of death from various bacterial, fungal and viral infections and is one of the most common and least–recognised illnesses. A sepsis arises when the body’s response to an infection injures its own tissues and organs. It may lead to shock, multiple organ failure and death if not treated promptly. If diagnosed and treated in the first hour, the patient has more than 80% survival rate. After the sixth hour, the patient only has a 30% survival rate.

Experts attributed sepsis for a chunk of mortality associated with malaria, dengue and pneumonia. "Sepsis is still not treated as a medical emergency because awareness is low and in many cases, deaths are misdiagnosed and attributed to underlying infections such as pneumonia rather than the true cause of death – sepsis," said Dr Palepu B Gopal, a critical care specialist and treasurer of the Indian Society for Critical Care Medicine (ISCCM). The symptoms of sepsis, experts said, are not widely recognised by healthcare professionals resulting in delay in appropriate treatment. Symptoms include a rapid heart rate, difficulty in breathing, low blood pressure, drowsiness or slurring words, diarrhoea, changes in skin colour and sore throat. Dr T Suhasini, president, ISCCM said that around 40–60% of the patients admitted in the ICUs of general hospitals suffer from sepsis and happen to report at a late stage. "Of these, 35–50% die," she said.

Everyone from an infant to an adult is at a potential risk of developing sepsis from common infections like flu, urinary tract infections, pneumonia and gastroenteritis, among others. Also, patients who are admitted to the hospital with serious diseases are at the highest risk of developing sepsis because of their underlying disease, previous use of antibiotics and presence of drug–resistant bacteria in the hospital. "Patients often require an intravenous tube, urinary catheter or wound drainage, which are the common sites of infection," said Dr D Manimala Rao, former president, ISCCM. Dr S Srinivas, secretary, ISCCM said that hospital acquired sepsis is more life threatening than the one acquired through common infections outside. ISCCM has joined hands with Global Sepsis Alliance to undertake awareness and educative programmes in line with global events to observe World Sepsis Day this year. (Source: TOI, Sep 12, 2012)

NEW DELHI: After a false start three years ago, Delhi may finally be on the road to being free of plastic bags. The Delhi cabinet on Tuesday approved imposition of a blanket ban on use, storage, sale and manufacture of plastic bags in the city. The new ban, more comprehensive and better thought out, will supersede the earlier notification issued in January 2009 that prohibited only the use, storage and sale of plastic bags in commercial areas. "There will be no leniency in implementing the blanket ban and crackdown on violators will be more aggressive this time," chief minister Sheila Dikshit said. A notification on the ban will be issued soon and the government will have one year from that date to implement the ban completely. The 2009 ban failed to make any difference in the city largely due to poor implementation. This time, the government has moved to plug loopholes in that law. The ban has been extended to include all plastic bags, even those made of virgin or bio–degradable plastic of 40 microns or more thickness, which had previously been permitted. The only exception will be use of plastic carry bags under the Bio–Medical Waste Management and Handling Rules of 1998. The ban now includes manufacturing of plastic bags and use of plastic sheets, films or covers for packaging books, magazines or cards. (Source: TOI, Sep 12, 2012)

Aspirin at arrival: The percentage of acute myocardial infarction (AMI) patients without aspirin contraindications who receive aspirin within 24 hours before or after hospital arrival. US National average performance is 99%.

Aspirin at discharge: The percentage of AMI patients without aspirin contraindications who were prescribed aspirin at hospital discharge. U National average performance is 99%.

Angiotensin–converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for left ventricular dysfunction (LVSD): The percentage of AMI patients with LVSD and without contraindications who are prescribed an ACE inhibitor or an ARB at hospital discharge. US National average performance is 96%.

Beta blocker at discharge: The percentage of AMI patients without beta-blocker contraindications who were prescribed a beta-blocker at hospital discharge. US National average performance is 98%.

Fibrinolytic medication within 30 minutes of arrival: The percentage of AMI patients with ST–segment elevation or left bundle branch block on the ECG closest to arrival time who receive fibrinolytic therapy and who have a time from hospital arrival to fibrinolysis of 30 minutes or less. US National average performance is 57%.

Percutaneous coronary intervention (PCI) within 90 minutes of arrival: The percentage of AMI patients, among those with ST–segment elevation or left bundle branch block on the ECG closest to arrival time who receive PCI and who have a time from hospital arrival to PCI of 90 minutes or less. US National average performance is 90%.

Smoking cessation advice/counseling: The percentage of AMI patients with a history of smoking cigarettes who are given smoking cessation advice or counseling during a hospital stay. US National average performance is 100%.

Median time to transfer to another facility for acute coronary intervention: The median time from emergency department (ED) arrival to transfer to another facility for acute coronary intervention among patients with ST–segment elevation or left bundle branch block on the ECG performed closest to ED arrival and who were transferred for acute coronary intervention. US National average performance is 61 minutes.

Median time to electrocardiogram (ECG): The median time from ED arrival to ECG for patients with AMI or probable cardiac chest pain. US National average performance is 8 minutes.

Low levels of sodium in the blood are associated with increased risk for death and complications within 30 days of having surgery, according to a study published online September 10 in the Archives of Internal Medicine. (Source: Medscape)

Using rapid antigen detection tests will help ensure that only confirmed cases of group A streptococcal pharyngitis –– strep throat –– will be treated with antibiotics, according to updated guidelines from the Infectious Diseases Society of America. Positive rapid test results do not need further confirmation with a throat culture, as the tests are highly specific and false–positives are rare, Stanford Shulman, MD, of Northwestern University Feinberg School of Medicine in Chicago, and colleagues stated in recommendations published online in Clinical Infectious Diseases. Negative tests, on the other hand, should be confirmed with throat cultures in children and adolescents, but not in adults, who have a low rate of group A streptococcal pharyngitis and a low risk for complications like acute rheumatic fever. The guideline, which updates previous recommendations released in 2002, noted that accurate diagnosis is necessary to target antibiotics to sore throats caused by strep and not those caused by other pathogens, usually viruses. Inappropriate use of antibiotics can lead to the development of drug resistance. (Source: Medpage Today)

Ads for prescription drugs that made the leap to over–the–counter (OTC) status were far less likely to warn about potential risks, researchers found. As prescription medications, 70% of ads for four drugs presented the potential harms compared with only 11% of ads for the same four drugs after they became available without a script, Jeremy Greene, MD, PhD, of Brigham & Women’s Hospital in Boston, and colleagues reported in a research letter in the Journal of the American Medical Association. (Source: Medpage Today)

Asthma patients may not have to shun exercise for fear of exacerbating their symptoms, a new study suggests. In fact, exercise could improve their symptoms and quality of life, according to research reported September 2 at the European Respiratory Society’s annual conference in Vienna, Austria. With attention to self management, increased physical activity did not worsen asthma control and in most cases was associated with improvement, said Dr. Carol Mancuso and her team at the Hospital for Special Surgery in New York City, in a presentation at the conference. (Source: Medscape)

Ejaculation can be achieved by directly stimulating nerves with an electrical probe placed in the rectum. Semen can be obtained in greater than 90% of neurologically impaired men, including those with lower spinal cord injuries for whom vibratory stimulation is usually unsuccessful. Some of the sperm go into the bladder rather than out of the penis. This is known as retrograde ejaculation. Retrograde ejaculation requires that sperm be retrieved from the urine.

Sometimes people come into your life and you know right away that they were meant to be there, to serve some sort of purpose, teach you a lesson, or to help you figure out who you are or who you want to become.

You never know who these people may be – a roommate, a neighbor, a professor, a friend, a lover, or even a complete stranger – but when you lock eyes with them, you know at that very moment they will affect your life in some profound way. Sometimes things happen to you that may seem horrible, painful, and unfair at first, but in reflection you find that without overcoming those obstacles you would have never realized your potential, strength, willpower, or heart.

Illness, injury, love, lost moments of true greatness, and sheer stupidity all occur to test the limits of your soul. Without these small tests, whatever they may be, life would be like a smoothly paved straight flat road to nowhere. It would be safe and comfortable, but dull and utterly pointless. The people you meet who affect your life, and the success and downfalls you experience, help to create who you are and who you become. Even the bad experiences can be learned from. In fact, they are sometimes the most important ones.

If someone loves you, give love back to them in whatever way you can, not only because they love you, but because in a way, they are teaching you to love and how to open your heart and eyes to things. If someone hurts you, betrays you, or breaks your heart, forgive them, for they have helped you learn about trust and the importance of being cautious to whom you open your heart. Make every day count. Appreciate every moment and take from those moments everything that you possibly can for you may never be able to experience it again. Talk to people that you have never talked to before, and listen to what they have to say.

Let yourself fall in love, break free, and set your sights high. Hold your head up because you have every right to. Tell yourself you are a great individual and believe in yourself, for if you don’t believe in yourself, it will be hard for others to believe in you. You can make anything you wish of your life. Create your own life and then go out and live it with absolutely no regrets.

And if you love someone tell them, for you never know what tomorrow may have in store. Learn a lesson in life each day that you live! Today is the tomorrow you were worried about yesterday. Think About it? Was it worth it?

Situation: A pregnant lady died. Dr Bad: Declare her dead. Dr Good: Deliver the infant within 5 minutes. Lesson: "Five minute rule" states that the best outcome with regards to neonatal neurological outcome is most likely when delivery occurs within five minutes of maternal cardiac arrest.

Studies showed that one 25–mg injection of purified ViCPS produced seroconversion (i.e. at least a fourfold rise in antibody titers) in 93% healthy individuals in USA and Europe. The field trials demonstrated the efficacy of ViCPS in preventing/reducing typhoid fever in Nepal, an area endemic for typhoid fever.

The other is the old, live attenuated oral ty21a vaccine available as capsules or sachets. Course of 3 capsules are given orally on alternate days (4 capsules on alternate days can also be given for inducing immunity which lasts for longer duration). Conjugate typhoid vaccines (combined with TT vaccine), are the newer vaccines which need more data on efficacy and safety, etc.

The clinical trials on typhoid vaccine were conducted by the Seoul–based International Vaccine Institute (IVI) in collaboration with the National Institute of Cholera and Enteric Diseases (NICED) of Kolkata, India. ICMR monitored the study’s progress and concluded that typhoid vaccines should be used where typhoid is endemic and causing high mortality and morbidity. Despite the availability of new generation typhoid injectable vaccines known as ViCPS vaccines, and a WHO recommendation for its use, they are administered sparsely in public health programmes.

In India, typhoid vaccines are optional and are not part of the national immunization programmes. However, some parts of Delhi introduced typhoid vaccination in 2004 for two– to five–year–old children. The vaccine has also been progressively introduced in school–going children vaccination programmes in other Asian countries.

Q. What are your comments regarding the violation of human rights of doctors by denying them permission to issue NORI certificate?

Ans.

You are obviously referring to a news item dated Sep 10, 2012 published in the Times of India, briefly summarised below––

"In a bid to prevent medical students who go to the US for higher studies from settling down there, the health ministry has suspended issuing ‘no obligation to return’ certificates which is mandatory for Indian doctors who have completed up to nine years of medical education to settle in the US. In fact, before they head there, the US requires the health ministry (of all developing countries) to issue a "statement of need" certificate, stating "the student is being allowed to go and study medicine in the US because he is required to return and serve India".

Joint secretary in the health ministry S K Rao said only 30% of those who go to the US return to work. "This year, we haven’t issued a single NORI certificate," he said.

Guidelines for medical study abroad by 2013

In a bid to tackle brain drain in the medical profession, the government, for the first time, is drawing up guidelines for medical students going to the US for studies. The guidelines, expected by January 2013, will also apply to students who have gone to the US this year.

"We have sent the guidelines to the law ministry for their comments. It will specify the conditions for medical students to leave India and go to the US for higher education," joint secretary in the health ministry S K Rao said. "We have no problem with students going to the US to study. But the US wants us to first issue a certificate saying we are allowing the student to go and study there because he or she is needed in India and then issue another mandatory certificate nine years later saying he isn't needed in India so that he can settled down there," added Rao, who handles international health."

Non–issuance of the NORI certificate is not a violation of human rights as defined in section 2(d) of the Protection of Human Rights Act, 1993. It is not also a violation of the fundamental rights guaranteed in part three of the Constitution.

The decision not to issue NORI to doctors is a matter of policy of the state and such policy is permissible as long as it does not violate any fundamental right.

That the above policy is not violative of FR is clear from the fact that nobody has filed a WP against it even though not a single NORI certificate has been issued this year as stated by the Joint Secretary in the health ministry.

Electrolytes (Sodium, Potassium, Chloride and Carbon dioxide): To help detect and evaluate the severity of an existing electrolyte imbalance and to monitor the effectiveness of treatment. Electrolytes may be affected by many conditions; with Addison’s disease the sodium, chloride, and carbon dioxide levels are often low, while the potassium level may be very high.

BUN and Creatinine are also done.

Mind Teaser

Read this…………………

Which of the following interventions would be included in the care of plan in a client with cervical implant?

Yesterday’s Mind Teaser: Which nursing measure would avoid constriction on the affected arm immediately after mastectomy?

A. Avoid BP measurement and constricting clothing on the affected arm
B. Active range of motion exercises of the arms once a day.
C. Discourage feeding, washing or combing with the affected arm
D. Place the affected arm in a dependent position, below the level of the heart

According to a new study published in the journal Pediatrics, obesity and metabolic syndrome can have an immediate impact on the learning abilities of children and teens. Currently, half of children and adolescents in the US are either overweight or obese, and of those a little over a third are struggling with metabolic syndrome. Metabolic syndrome is characterized by three or more heart risk factors such as abdominal obesity, high cholesterol levels, elevated blood sugar, and high blood pressure.

Results of the study showed children and teens who were diagnosed with metabolic syndrome performed about 10% worse on cognitive intellectual tests, assessing among other things attention and math and reading skills, than their healthier peers. In addition, researchers performed MRI scans on all 110 participants and found that obese children with metabolic syndrome showed a 10% reduction in the size of the hippocampus, the part of the brain responsible for forming, organizing, and storing memories.

An abundance of evidence shows that physical activity not only helps reduce obesity and improve symptoms of metabolic syndrome, but also positively impacts academic performance and concentration. Children should engage in at least 60 minutes of moderate physical activity on a daily basis to see health benefits.

Laugh a While (Dr GM Singh)

For Sale

A real–estate agent was driving around with a new trainee when she spotted a charming little farmhouse with a hand–lettered "For Sale" sign out front. After briskly introducing herself and her associate to the startled occupant, the agent cruised from room to room, opening closets and cupboards, testing faucets and pointing out where a "new light fixture here and a little paint there" would help. Pleased with her assertiveness, the woman was hopeful that the owner would offer her the listing.

"Ma’am," the man said, "I appreciate the home–improvement tips and all, but I think you read my sign wrong. It says, "HORSE for sale."

When an autopsy is conducted on a body, surgical interventions are made for internal examination that may damage blood vessels and organs, cause skull bone fracture, etc. These are the artifacts of postmortem examination and absolutely unrelated with the natural state of the dead body. Sometimes, it is grossly mistaken, especially in cases of repeat autopsy taking place in a different center.

Using chisel and hammer to loosen the skull cap may produce additional fractures or may cause extension of an already present antemortem fracture.

Rough handling of the brain during removal may produce midbrain tears. If the neck structures are pulled too hard during autopsy, they may be torn.

Pulling of the dura in the sagittal line will cause the air to enter the blood vessels at the top of the brain. Due to the reflection of the skin, air may enter the veins of the neck. This may lead to erroneous diagnosis of air embolism.

In case of a suspected cranial injury, the body should be opened, and the cardiovascular system decompressed by opening heart before the head is opened.

Large blood vessels may be cut while opening the thoracic and abdominal cavities, and considerable amount of blood escapes to the pleural and peritoneal cavities.

Air may be drawn back into the circulation and enter coronary vessels and give false impression of air embolism.

During autopsy, the handling of organs and incision of vessels may result in extravasation of blood into the tissues.

In older persons, the hyoid bones and thyroid cartilage may be fractured while removing the neck organs. Surrounding the fracture regions, hemorrhages are not seen.

Osseous union between the segments of hyoid may be unilateral. Such unilateral mobility or artefact by dissection may lead to erroneous impression of an antemortem fracture.

While dissecting the neck structures, if toothed dissecting forceps are used, it may damage the intima of the carotid artery which resembles a tear, as seen in case of strangulation.

The toxicological artefacts may be introduced due to the contamination of viscera with stomach contents due to autopsy, or by putting all the organs in one container or by using faulty techniques in collecting or storage of samples.

Typhoid fever is caused by a bacteria Salmonella typhi and is transmitted through the ingestion of food or drink contaminated by the feces or urine of infected people, said Padma Shri and Dr B C Roy National Awardee Dr K K Aggarwal, President Heart Care Foundation of India and Dil Ka Darbar to be held at Talkatora Stadium on the 23rd of this month.

Flying insects feeding on feces may occasionally transfer the bacteria through poor hygiene habits and public sanitation conditions. Though the cases occur all through the year, the number is higher during the summer and rainy seasons.

Symptoms usually develop 1 to 3 weeks after exposure, and may be mild or severe. They include high fever, malaise, headache, constipation or diarrhea and enlarged spleen and liver. A healthy carrier state may follow acute illness.

Typhoid fever can be treated with antibiotics. However, resistance to common antimicrobials is widespread. Healthy carriers should be excluded from handling food.

Sanitation and hygiene are the critical measures that can be taken to prevent typhoid.

Typhoid does not affect animals and therefore transmission occurs only from human to human.

Typhoid can only spread in environments where human feces or urine are able to come into contact with food or drinking water.

Careful food preparation and washing of hands are crucial to preventing typhoid.

Typhoid fever in most cases is not fatal.

Prompt treatment of the disease with antibiotics reduces the case–fatality rate to approximately 1%.

When untreated, typhoid fever may persist for three weeks to a month.

Resistance to common antibiotics is now common.

Typhoid that is resistant to common antibiotics is known as multidrug–resistant typhoid (MDR typhoid).

Ciprofloxacin resistance is an increasing problem, especially in the Indian subcontinent and Southeast Asia.

Azithromycin is a new drug for drug–resistant typhoid.

Typhoid vaccine taken every three years is the best preventive approach.

Readers Responses

Dear sir, citalopram is SSRI antidepressant medicine not antipsychotic as mentioned in the legal section Dr.R.Mani.